Won’t “unspecified” codes cover for inaccuracies? No. Here’s why.

Like its predecessor, the ICD-10 standard still includes “unspecified” codes, but these are largely to be used only when a situation is truly inconclusive and test results have not yet been completed. However, even here, the new standard should include specific symptom codes, which should be used instead of an unspecified one if possible.

Keep in mind that payers are and will continue to update their edits and policies with regard to their acceptance of the “unspecified” code.

As long as specific codes exist for patient symptoms, tests, diagnoses, episodes and so on, we strongly encourage cross-mapping to convert currently unspecified codes into the more specific codes in the ICD-10 standard when applicable.

Now that the transition to the ICD-10 code set is no longer a moving target, hospitals and physician offices have been aggressively working to make their transitions successful. Investments in technology are well under way. And processes are being developed. Yet many physicians do not feel ready.

Some physicians are struggling with the volume of new codes — and the significant new requirements for using them. And the degree to which physicians can code patient visits accurately and completely will define the difference between successful implementations and failures.

There’s nothing else we can do now – or is there?

With less than a month until October 1, it might seem as if any action that isn’t already part of your plan will be pointless. Not true. We’ve identified six critical steps that hospitals and their physicians should take to support physician readiness, all of which can be added to existing plans right now:

  1. Conduct a documentation review – internal, external or both

    At a minimum, any documentation review should include an analysis of how documentation flows from physicians to coders to billing to payers and so on. It should also review each provider’s documentation, identifying any existing issues. Keep in mind, any existing ICD-9 issues will not magically disappear once the new standard is in place.

    And, your review should evaluate how well staff members use your EHR technology, since these systems will be critical to successful ICD-10 code usage. An internal review may be the easiest to conduct. However, an internal review may gloss over issues that have become so common that they are invisible. A third-party review can corroborate the findings of an internal review, while providing insights and perspectives that can more rapidly bring important opportunities for improvement to everyone’s attention.

  2. Cross-map your top 25 codes

    No individual physician will use all 68,000 codes in the ICD-10 standard. However, each physician uses around 25 ICD-9 codes frequently. Identify those codes and then cross-map them to the appropriate ICD-10 codes. Even though each ICD-9 code will map to multiple ICD-10 codes, this exercise can help physicians reduce the new system to a more manageable size, enabling them to feel ready and able to document most of the cases they see in any given day.

  3. Test your claims

    You should look at successful ICD-9 codes submitted over the past year and test them against the ICD-10 standard. Re-code claims as you would under the new system and confirm that your reimbursements would be comparable. Yes, this is time consuming, but October 1 should not be the first time that physicians and coders are using the new standard.

  4. Talk with your top payers

    It is both valid and necessary that you learn what the top payers in your state will and will not accept as healthcare systems nationwide transition to this dramatically different system. CMS says it won't deny claims for a year based solely on the lack of assigning the highest specificity of ICD-10, and it is possible that some other payers may accept unspecified codes in the first month or two of the new system – but after that, they may require specific codes for everything. By taking your payers’ preferences into account, you can dramatically increase your ability to submit accurate claims.

  5. Treat training as an ongoing effort not a one-time event

    Once the new system is implemented, success will depend on your ability to engage in a cycle of claims monitoring, examining them for issues that are yielding denials or insufficient payment, communicating issues back to doctors and coders, and pursuing continued education to remedy problems. In short, your ICD-10 committee needs to remain engaged on usage of the new standard well beyond the October cutover.

  6. Establish specific communication processes

    “This is the first I’m hearing about that!” is the phrase we hear most commonly in the work we’ve been doing to help hospitals and health systems prepare their physicians for the ICD-10 cutover. We respond by going back through the communications chain and sure enough, we find places where communication processes are nonexistent or broken. Often, it’s because leaders who are living and breathing the transition from ICD-9 to ICD-10 find it difficult or impossible to imagine that anyone else isn’t equally aware.

    The truth is that if you don’t have a clear, direct plan for communicating critical issues, you cannot assume that the people who receive the reports you generate are sharing information with others who need to hear it. Especially as we race ahead to the cutover deadline, you’ve got to establish and codify how, when, how often and with whom key information must be shared.

Bonus step: Expect the unexpected

Chances are that your existing plan includes time during September when you’ll be working with a dual code-set as claims are being submitted using ICD-9 and being tested in ICD-10. Have you taken into account how much that may slow down operations? Of course, a dual coding system in and of itself will duplicate efforts, straining productivity. Beyond that, however, is the time necessary to track down claims that were not coded correctly. That will cut into the time physicians can spend with patients, which not only can create longer workdays but also affect patient care.

Even with excellent planning in place, you cannot predict exactly which possible scenarios may affect productivity, efficiency and effectiveness. But you can predict that they are likely to happen. And you can plan for it. Compared to the costs of a serious productivity slowdown, appointment backups or even delays in patient care, the cost of bringing in extra support to help your organization confidently manage through the transition may be worth the short-term investment.

October is coming – and you can get your physicians ready

The combination of a rapidly approaching deadline and physicians who feel underprepared for the ICD-10 transition actually offers an excellent opportunity for physician and hospital leaders. With the urgency of the situation clear, the time is now to take the critical steps that will help alleviate physician insecurities, improve readiness, yield accurate and complete physician documentation – and carry your organization through a successful ICD-10 transition.

Author - Female

About the author

Cindy Cain, BSHA, CPC, CPC-H, CCS-P, CHC is Director for Consulting with McKesson Business Performance Services, an approved ICD-10-CM trainer and an ambassador with the American Health Information Management Association (AHIMA) with more than 25 years of multi-specialty healthcare experience.